The applicability of fingernail lead and cadmium levels as subchronic exposure biomarkers for preschool children

Preschool children are exposed daily to metals in their homes and at daycare centers (DCC). Metal exposure and health effects are associated even at low levels, and children comprise a group of public health concern. Nail metals have been studied for exposure biomonitoring and compared to other biological media. The aim of this study was to explore the applicability of preschool fingernail lead and cadmium as subchronic exposure biomarkers. Nail lead and cadmium levels (NLL and NCL) of 602 preschool children (age: 1-4 years) who attended 21 DCC in São Paulo, Brazil, in 2013 were analyzed. Results were compared against blood lead and cadmium levels (BLL and BCL) found in a previous study. Inductively coupled plasma mass spectrometry (ICP-MS) analyses were performed for both samples. DCC and metal contaminated sites (MCS) were georeferencing. Logistic regression tests were applied to verify associations between nail metal levels and risk factors (sex, age, maternal education, secondary smoking, DCC geographic district, vehicle flow density, relative altitude and distance between DCC and nearest MCS) (p < 0.05). BLL was stratified by exposure level (low: <5 μg.dL^-1; high: >13.9 μg.dL^-1; medium: ≥5 μg.dL^-1 and ≤13.9 μg.dL^-1) and also tested the associations in order to verify if nail lead levels are affected by exposure intensity defined by blood metals concentrations. Radius distance and relative altitude of DCC to nearest MCS were associated with high NLL and NCL. Abnormal appearance of nails was associated with high NLL and low NCL. Lead and cadmium exposure magnitude had no significant impact on NLL. NLL should only be used for initial screening, and when financial resources are scarce, especially in areas located near contaminated sites. Preschool children were co-exposed to both lead and cadmium, reinforcing the need for broader studies evaluating exposure to environmental pollutants for more than one chemical element.

Primary hepatic neuroendocrine tumor: A case report and literature review

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Primary hepatic neuroendocrine tumors are rare neoplasms, with less than 200 cases reported.

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The clinical presentation of PHNETs is non-specific and its radiologic features are intensely diversified.

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Surgical resection with clear margins is the mainstay treatment for PHNETs, with very positive results.

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For unresectable tumors, liver transplantation and transcatheter arterial chemoembolization are the main options.

Introduction

Primary hepatic neuroendocrine tumors (PHNETs) are extremely rare, having less than 200 cases reported in the literature.

Presentation of case

A 51-year-old woman presenting with mild intensity sharp pain in the upper abdomen that started 4 years ago. Preoperative Magnetic Resonance Imaging (MRI) suggested hepatocellular adenoma. Surgical exploration found a tumor occupying the whole segment IV of the liver, therefore a left hepatectomy was performed. Pathology and immunohistochemistry indicated to be a low-grade neuroendocrine tumor of the liver. The patient is enjoying a good quality of life, free of disease, presenting no signs of recurrence nor metastases 12 months after the procedure.

Conclusion

The clinical presentation of PHNETs is non-specific and its radiologic features are intensely diversified, frequently leading to misdiagnosis of other hepatic neoplasms.

Interreader Reliability of LI-RADS Version 2014 Algorithm and Imaging Features for Diagnosis of Hepatocellular Carcinoma: A Large International Multireader Study

Purpose To determine in a large multicenter multireader setting the interreader reliability of Liver Imaging Reporting and Data System (LI-RADS) version 2014 categories, the major imaging features seen with computed tomography (CT) and magnetic resonance (MR) imaging, and the potential effect of reader demographics on agreement with a preselected nonconsecutive image set. Materials and Methods Institutional review board approval was obtained, and patient consent was waived for this retrospective study. Ten image sets, comprising 38-40 unique studies (equal number of CT and MR imaging studies, uniformly distributed LI-RADS categories), were randomly allocated to readers. Images were acquired in unenhanced and standard contrast material-enhanced phases, with observation diameter and growth data provided. Readers completed a demographic survey, assigned LI-RADS version 2014 categories, and assessed major features. Intraclass correlation coefficient (ICC) assessed with mixed-model regression analyses was the metric for interreader reliability of assigning categories and major features. Results A total of 113 readers evaluated 380 image sets. ICC of final LI-RADS category assignment was 0.67 (95% confidence interval [CI]: 0.61, 0.71) for CT and 0.73 (95% CI: 0.68, 0.77) for MR imaging. ICC was 0.87 (95% CI: 0.84, 0.90) for arterial phase hyperenhancement, 0.85 (95% CI: 0.81, 0.88) for washout appearance, and 0.84 (95% CI: 0.80, 0.87) for capsule appearance. ICC was not significantly affected by liver expertise, LI-RADS familiarity, or years of postresidency practice (ICC range, 0.69-0.70; ICC difference, 0.003-0.01 [95% CI: -0.003 to -0.01, 0.004-0.02]. ICC was borderline higher for private practice readers than for academic readers (ICC difference, 0.009; 95% CI: 0.000, 0.021). Conclusion ICC is good for final LI-RADS categorization and high for major feature characterization, with minimal reader demographic effect. Of note, our results using selected image sets from nonconsecutive examinations are not necessarily comparable with those of prior studies that used consecutive examination series. ^© RSNA, 2017.

Imaging Outcomes of Liver Imaging Reporting and Data System Version 2014 Category 2, 3, and 4 Observations Detected at CT and MR Imaging

Purpose To determine the proportion of untreated Liver Imaging Reporting and Data System (LI-RADS) version 2014 category 2, 3, and 4 observations that progress, remain stable, or decrease in category and to compare the cumulative incidence of progression in category. Materials and Methods In this retrospective, longitudinal, single-center, HIPAA-compliant, institutional review board-approved study, 157 patients (86 men and 71 women; mean age ± standard deviation, 59.0 years ± 9.7) underwent two or more multiphasic computed tomographic (CT) or magnetic resonance (MR) imaging examinations for hepatocellular carcinoma surveillance, with the first examination in 2011 or 2012. One radiologist reviewed baseline and follow-up CT and MR images (mean follow-up, 614 days). LI-RADS categories issued in the clinical reports by using version 1.0 or version 2013 were converted to version 2014 retrospectively; category modifications were verified with another radiologist. For index category LR-2, LR-3, and LR-4 observations, the proportions that progressed, remained stable, or decreased in category were calculated. Cumulative incidence curves for progression were compared according to baseline LI-RADS category (by using log-rank tests). Results All 63 index LR-2 observations remained stable or decreased in category. Among 166 index LR-3 observations, seven (4%) progressed to LR-5, and eight (5%) progressed to LR-4. Among 52 index LR-4 observations, 20 (38%) progressed to a malignant category. The cumulative incidence of progression to a malignant category was higher for index LR-4 observations than for index LR-3 or LR-2 observations (each P < .001) but was not different between LR-3 and LR-2 observations (P = .155). The cumulative incidence of progression to at least category LR-4 was trend-level higher for index LR-3 observations than for LR-2 observations (P = .0502). Conclusion Observations classified according to LI-RADS version 2014 categories are associated with different imaging outcomes. (©) RSNA, 2016 Online supplemental material is available for this article.

Diagnostic Accuracy of Preoperative Gadoxetic Acid-enhanced 3-T MR Imaging for Malignant Liver Lesions by Using Ex Vivo MR Imaging-matched Pathologic Findings as the Reference Standard

PURPOSE

To determine per-lesion sensitivity and positive predictive value (PPV) of gadoxetic acid-enhanced 3-T magnetic resonance (MR) imaging for the diagnosis of malignant lesions by using matched (spatially correlated) hepatectomy pathologic findings as the reference standard. Materials and

METHODS

In this prospective, institutional review board-approved, HIPAA-compliant study, 20 patients (nine men, 11 women; mean age, 59 years) with malignant liver lesions who gave written informed consent underwent preoperative gadoxetic acid-enhanced 3-T MR imaging for surgical planning. Two image sets were independently analyzed by three readers to detect liver lesions (set 1 without and set 2 with hepatobiliary phase [HBP] images). Hepatectomy specimen ex vivo MR imaging assisted in matching gadoxetic acid-enhanced 3-T MR imaging findings with pathologic findings. Interreader agreement was assessed by using the Cohen κ coefficient. Per-lesion sensitivity and PPV were calculated.

RESULTS

Cohen κ values were 0.64-0.76 and 0.57-0.84, and overall per-lesion sensitivity was 45% (42 of 94 lesions) to 56% (53 of 94 lesions) and 58% (55 of 94 lesions) to 64% (60 of 94 lesions) for sets 1 and 2, respectively. The addition of HBP imaging did not affect interreader agreement but significantly improved overall sensitivity for one reader (P < .05) and almost for another (P = .05). Sensitivity for 0.2-0.5-cm lesions was 0% (0 of 26 lesions) to 8% (two of 26 lesions) for set 1 and 4% (one of 26 lesions) to 12% (three of 26 lesions) for set 2. Sensitivity for 0.6-1.0-cm lesions was 28% (nine of 32 lesions) to 59% (19 of 32 lesions) for set 1 and 66% (21 of 32 lesions) to 69% (22 of 32 lesions) for set 2. Sensitivity for lesions at least 1.0 cm in diameter was at least 81% (13 of 16 lesions) for set 1 and was not improved for set 2. PPV was 98% (56 of 57 lesions) to 100% (60 of 60 lesions) for all readers without differences between image sets or lesion size.

CONCLUSION

Gadoxetic acid-enhanced 3-T MR imaging provides high per-lesion sensitivity and PPV for preoperative malignant liver lesion detection overall, although sensitivity for 0.2-0.5-cm malignant lesions is poor.